Specialist, Payment Integrity

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Requirements:

• 3+ years of experience in claims processing, coding, auditing or health care operations
• 3+ years experience in medical coding
• Medical coding certification through AAPC (CPC, COC) or AHIMA (CCS, RHIT, RHIA)
• Experience with reimbursement methodologies, provider contract concepts and common claims processing/resolution practices.
• 2+ years experience deriving business insights from datasets and solving problems
• 1+ years experience improving business workflows and processes
• 1+ years experience collaborating with internal and/or external stakeholders

Responsibilities:

• Contribute as a subject matter expert for Oscar reimbursement policies, payment integrity internal claims processing edits and external vendor edits.
• Respond to internal and external inquiries and disputes regarding policies and edits.
• Research industry standard coding rules, summarize and provide input into reimbursement policy language and scope.
• Use knowledge gained through research and claims review to ideate payment integrity opportunities. Translate into business requirements; submit to and collaborate with internal partners to effectuate change.
• Ingest information from internal and external partners regarding adverse claim outcomes; collaborate with partners to scope, size, prioritize items and deliver solutions.
• Use insights from partner submissions, data mining, process monitoring, etc., work with the team to proactively identify thematic areas of opportunity to solve problems.
• Perpetuate a culture of transparency and collaboration by keeping stakeholders well informed of progress, status changes, blockers, completion, etc.; field questions as appropriate.
• Support Oscar run state objectives by providing speedy research, root cause analysis, training, etc. whenever issues are escalated and assigned by leadership.
• Compliance with all applicable laws and regulations
• Other duties as assigned